Individualised Cardiac Index-Guided Therapy Fails to Reduce Postoperative Complications in High-Risk Surgery, JAMA Trial Finds

Maintaining adequate tissue perfusion during major surgery is essential for preventing postoperative kidney injury, myocardial damage and other serious complications. Conventional intraoperative haemodynamic management relies primarily on blood pressure, fluid administration and clinical assessment. Advanced cardiac output monitoring has been proposed to improve outcomes by individualising circulatory support. However, whether targeting a patient's preoperative cardiac index offers additional clinical benefits remains uncertain.

A new randomised clinical trial published in JAMA has found that individualised cardiac index-guided haemodynamic therapy did not significantly reduce major postoperative complications compared with routine management in high-risk patients undergoing elective abdominal surgery.

The study, titled “Individualized Cardiac Index–Guided Hemodynamic Therapy in High-Risk Patients Undergoing Elective Major Abdominal Surgery: The PELICAN Randomized Clinical Trial,” was conducted by Bernd Saugel and colleagues across 12 university medical centres in Austria, the Czech Republic, Denmark, Germany and Spain.

The multicentre, single-blind trial enrolled 1,128 patients, of whom 1,095 were included in the primary analysis. The median age was 67 years, and approximately 49% were women.

Participants were randomly assigned to individualised cardiac index-guided therapy or routine haemodynamic management.

In the intervention group, clinicians attempted to maintain intraoperative cardiac index at or above each patient's preoperative resting value using intravenous fluids and dobutamine according to a treatment algorithm. In the control group, haemodynamic management was guided by the attending anaesthesiologist, with cardiac index measurements concealed.

Both groups aimed to maintain mean arterial pressure above 65 mmHg.

The primary outcome was a composite of acute kidney injury, acute myocardial injury, severe infectious complications, nonfatal cardiac arrest or death within seven postoperative days.

The investigators reported the following key findings:

• The primary composite outcome occurred in 44.3% of patients receiving cardiac index-guided therapy compared with 46.9% receiving routine care.

• The relative risk was 0.94 (95.1% CI, 0.83–1.08; P=0.38), indicating no statistically significant benefit.

• Acute kidney injury occurred in 9.6% versus 13.0% of patients, respectively, but the difference was not statistically significant.

• Acute myocardial injury occurred in 29.8% versus 31.2%, while severe infectious complications occurred in approximately 21% of both groups.

• Patients receiving individualised therapy received more intravenous fluid, with a median volume of 3,500 mL compared with 2,838 mL.

• Dobutamine was administered to 64.1% of intervention patients compared with only 0.5% receiving routine care.

Although the intervention successfully increased intraoperative cardiac index, this physiological improvement did not translate into better postoperative outcomes.

An important secondary observation was higher 90-day mortality in the intervention group, at 5.7% compared with 2.8% in the control group. This finding warrants further investigation but should be interpreted cautiously because it was a secondary outcome and the trial was not designed to establish a mortality difference.

The findings challenge the assumption that maintaining cardiac index at preoperative resting levels necessarily improves organ perfusion sufficiently to prevent postoperative complications.

They also highlight that achieving a haemodynamic target does not automatically translate into improved clinical outcomes, particularly when additional fluids and inotropes are required.

For anaesthesiologists and perioperative physicians, the results emphasise the importance of avoiding unnecessary haemodynamic interventions based solely on cardiac index measurements.

The trial was limited to high-risk elective abdominal surgery and used bioreactance-based cardiac index monitoring. Its findings therefore cannot be generalised to every surgical population or monitoring technique.

Clinical Message: Routine individualised cardiac index-guided therapy targeting preoperative resting values did not reduce major postoperative complications in high-risk abdominal surgery. Advanced haemodynamic monitoring may provide useful physiological information, but treatment decisions should consider blood pressure, tissue perfusion, fluid responsiveness and the patient's overall condition rather than cardiac index targets alone.

Reference:

Saugel B, Meidert AS, Meyhoff CS, et al. Individualized Cardiac Index–Guided Hemodynamic Therapy in High-Risk Patients Undergoing Elective Major Abdominal Surgery: The PELICAN Randomized Clinical Trial. JAMA. Published online October 19, 2026.